Oncology medications and supportive agents prior authorization and review
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This policy governs prior review/authorization requirements for oncology medications and supportive agents for Medicare - Wellcare by Fidelis Care members, specifying drugs and HCPCS/J-codes that require review by Evolent/New Century Health and which requests are out of scope. It applies to participating providers and describes submission channels.
No material clinical or coverage changes in this revision.
Coverage Criteria and Authorization Preconditions
Authorization precondition
Covered when the following administrative conditions are met
Omission of any agent from the submitted oncology regimen to Evolent may result in a denial.
Out-of-scope services
Requests that should NOT be submitted to New Century Health (Out of scope)
These items are explicitly listed as out of scope and should NOT be submitted to NCH.
This policy excludes review by New Century Health (Evolent) for a defined list of out-of-scope services. Do NOT submit requests for the following items to NCH: antibiotics; bone marrow or stem cell transplants and CAR‑T cell therapy; controlled substances (e.g., morphine); equipment requests (for example infusion pumps); genetic laboratory testing and laboratory services; hemophilia drugs; inpatient drug requests; inpatient radiation and chemotherapy; iron preparations; radiopharmaceuticals; surgeries/surgical procedures; sickle cell diagnoses and related therapies; and immune globulins. These exclusions are administrative: they are not routed to NCH for prior review under this policy and should be handled through the appropriate inpatient or plan processes.
Submission Requirements for Oncology Regimens
| Requirement | Details | Coverage status |
|---|---|---|
| Submit entire oncology regimen to Evolent (formerly New Century Health) | ||
| All oncology regimens (medical and pharmacy benefit agents) must be submitted to Evolent via the NCH web portal (my.newcenturyhealth.com) or by phone (1-888-999-7713, option 1). Non-participating providers must submit requests to the plan via fax (1-844-235-5090). | ||
| Omission of any agent from the submitted oncology regimen may result in a denial. |
| Biosimilar class / category | Preferred biosimilar agents (examples listed in policy) | Submission requirement |
|---|---|---|
| Erythropoiesis-stimulating and hematopoietic agents | ||
| Examples include Zarxio (medical & pharmacy benefit) and filgrastim biosimilars (Q5101, Q5110) as listed in the policy. | ||
| Preferred biosimilars still require submission to New Century Health for review prior to dispensing or administration. |
Drug and Code Lists
| C9142 | BEVACIZUMAB-MALY. |
| J0185 | APREPITANT INJ. |
| J0881 | DARBEPOETIN ALFA NON-ESRD. |
| J1447 | TBO-FILGRASTIM |
| J2506 | PEGFILGRASTIM (ON-BODY INJECTOR) / PEGFILGRASTIM INJECTION |
| J9019 | ERWINAZE INJ |
| J9200 | FLOXURIDINE INJ |
| J9271 | PEMBROLIZUMAB |
| J9317 | PERTUZUMAB/TRASTUZUMAB/HYAL INJ |
| J9355 | TRASTUZUMAB INJ |
Provider Submission Instructions and Requirements
Prior review required by New Century Health
Oncology medications and supportive agents listed by HCPCS/J-codes must be reviewed by Evolent (formerly New Century Health) before being dispensed at a pharmacy or administered in outpatient/ambulatory settings for participating providers.
- Includes drugs available via medical or pharmacy benefit and pharmacy-only agents (see HCPCS/J-code lists).
- Requirement applies to dispensing at a pharmacy or administration in a physician's office, outpatient hospital, or ambulatory setting.
Preferred biosimilars still require submission
Preferred biosimilar agents remain subject to New Century Health review — preferred status does not remove the requirement to submit the agent to NCH for review.
- Examples of classes with preferred biosimilars include erythropoiesis-stimulating agents, trastuzumab, bevacizumab, and rituximab.
How to submit and what to include
Submit the entire oncology regimen to Evolent (formerly New Century Health) via the NCH web portal (my.newcenturyhealth.com) or by calling 1-888-999-7713, option 1; non‑participating providers must submit requests to the plan by fax at 1-844-235-5090.
- Include the full regimen (all medical and pharmacy benefit agents) when submitting.
- Clinical trials may be sent to Evolent for review.
Denial risk for incomplete regimen submission
Omission of any agent from the submitted oncology regimen may result in a denial of the request.
- Ensure every agent in the planned regimen (medical and pharmacy benefit) is listed on the submission.
- The policy explicitly notes that any omissions may result in denial.
Definitions and Out-of-Scope Items
Background
This administrative policy establishes utilization management for oncology medications and supportive agents by requiring external review by Evolent (formerly New Century Health). Prior review is required for oncology drugs and supportive agents furnished in outpatient/ambulatory settings; participating providers must submit requests to Evolent, and non‑participating providers must submit to the plan via fax as specified. Submit the entire oncology regimen for review—omitting any agent from the submitted regimen may result in a denial. Requests can be submitted via the NCH web portal (my.newcenturyhealth.com) or by phone as provided; non‑participating providers should use the plan fax number.
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